23

DELUSIONAL DISORDER
Wong Kim Eng

Case History Ah Seng, a 55-year-old divorced coffee shop assistant, was remanded at the state mental hospital a total of four times in 5 years, for distributing seditious materials. He was convinced that the government was oppressing the poor people and infiltrating an opposition party with their stooges in order to make the opposition look foolish. He thus saw it his duty to distribute anti-government materials to force the government to step down. His resentment for the government first began decades ago when his family had to be resettled after the government acquired the land they were living on. His siblings were equally upset by the resettlement too. However, it was not till years later that, while in his fifties, he began to develop systematized delusions about how the government was doing wrong to the people. Ah Seng interpreted every action of the government as a ruse to oppress the poor people. He believed that drug taking flourished because the government caught only the middlemen, but colluded with the drug lords. In tandem with his delusion of persecution by the government, he also harboured grandiose delusions of having the power of causing national calamities and deaths of prominent political figures by the sheer force of his prayers. As an example, he cited a politicians suicide that was caused by his prayers. He did not possess any other abnormal symptoms such as auditory hallucinations, passivity influence, or thought disorder. His behaviour outside of his political beliefs was otherwise normal. No medical condition was found to explain his beliefs. Despite his persecutory and grandiose delusions, his friends and siblings did not think his ideas were abnormal, and he was able to eke out a simple living for himself by working at simple jobs. He refused to have any treatment, a decision that was strongly supported by his family.

Introduction A delusion is a firm, unshakeable, false belief that is out of keeping with the persons social, educational, and cultural background. A delusional disorder is a condition where the person, usually middle-aged or older, develops an insidious onset of long-standing encapsulated, non-bizarre delusions. Bizarreness of the delusion may be difficult to ascertain, especially amongst different cultures. Generally, delusions may be considered bizarre if they are not understandable, are out of keeping with lifes ordinary experiences, and involve situations that do not plausibly occur in real life. The central theme of the delusional system may be persecutory, grandiose, jealousy, erotic, somatic, or mixed. Unlike in Schizophrenia, auditory and visual hallucinations are not prominent, even if present. The persons other mental functions are normal, his personality is generally intact, and he is able to work and interact reasonably with others. Defined in this manner, delusional disorders are uncommon, as eventually most of them turn out to be early manifestations of schizophrenia. No local figures are available, but an estimate of the

American population prevalence is about 0.03%, while it is thought to account for 1-2% of inpatient admissions.

Subtypes of delusional disorders (a) Persecutory delusional disorder

The commonest type of delusional disorder, the affected individual believes that he is being checked, spied on, harassed, obstructed, conspired against, poisoned, or followed. As a result, he may resort to violence in retaliation against the persecution, or engage in repeated appeals to the courts and other government agencies to right the injustice. In the case of Ah Seng, his persecutory delusions centred on the harassment of the poor people by the government, and not just on him personally. Most government actions were interpreted as part of the systematized plot to make the poor people suffer, and to discredit the opposition so that the government could stay in power. Ah Seng thus resorted to distribution of seditious materials to right the injustice done to the people. (b) Grandiose delusional disorder

The individual is convinced that he has a great talent, or special religious powers, or a special relationship with a prominent person. In the case of Ah Seng, he was certain that he had special religious powers to cause national disasters and the suicide of a prominent politician, all of which he weaved into his political persecutory delusional ideas in a systematized manner. He was deluded that his special powers had evolved from his vegetarian diet and his daily prayers. Apart from his grandiose delusions, Ah Seng did not display other symptoms or signs suggestive of a hypomanic/manic state. (c) Erotomanic (or delusion of love) delusional disorder

A 35-year-old single clerk was deluded that a fellow church member, who was a company executive, was in love with her. She took to stalking him at his home. When she found him going out with another woman, she was so incensed with jealousy that she attacked the woman, and was remanded. The central theme of erotomania, as shown in the example above, is that another person of a higher status (a superior at work or a famous person), is in love with the individual, but is usually unable to demonstrate the love because of certain obstacles in their lives. Outpatients with erotomania tend to be females, while remanded in-patients tend to be males. Erotomanic delusional disorder is sometimes referred to as De Clerambaults Syndrome. (d) Jealous delusional disorder

A 62-year-old elderly and unattractive man was remanded for locking in and seriously attacking his 45-year-old attractive wife at home. Both his teenage children readily testified to his unfounded jealous rantings and checks on his wife for years. It transpired that his first marriage had ended in divorce when his first wife could not tolerate his delusions of infidelity, although he did not assault her then.

The central theme revolves round the delusion of infidelity of the spouse or partner. The diagnosis is made when jealousy is based on inadequate/unsound evidence and reasoning. Little bits of evidence are used to reinforce the belief that the spouse is carrying on an affair. The individual would painstakingly check the spouses intimate belongings for evidence of the affair (such as seminal fluid stains on the underwear) or monitor the spouses movements for incriminating evidence of a third party. In its severe form, as shown in the case cited above, the individual may be so jealous that he resorts to assaults on, or homicide of, the spouse. This is the most dangerous, and is also one of the commonest forms of delusional disorders. Evidence available so far indicates that it is commoner in males than females. It is sometimes known as morbid jealousy or pathological jealousy. (e) Somatic delusional disorder

For 5 years a 35-year-old man was convinced that the blood in his left brain was flowing backwards, thus causing a block, and making his head uncomfortable and painful. He adhered to his belief tenaciously despite repeated reassurances by various neurologists. Not surprisingly, he was non-compliant with medications and, eventually jumped to his death when the symptom became intolerable. Often the central theme in somatic delusional disorder is that of the conviction that the individual emits a foul odour from the mouth, skin, or genitalia; or that parts of the body are misshapen or ugly; or that there are parasites on the body. Sometimes tactile or olfactory hallucinations may be prominent. The example above exemplifies the condition known as Monosymptomatic Hypochondriacal Psychosis, which is included in somatic delusional disorder.

Induced delusional disorder (folie a deux) This is a rare delusional disorder where two people, usually in a very close relationship and are isolated from others by culture, language or physical proximity, share the same delusional system. The theme of the delusional system is often persecutory or grandiose. The delusions are first manifested in the dominant personality, who in turn influences the weaker personality. The former is the only psychotic one, whilst the latter would recover promptly once separation is effected. The delusional system may be part of Schizophrenia, or it may be a primary delusional disorder in itself.

Predisposing factors to delusional disorder People most at risk are usually found in these circumstances: (a) (b) (c) (d) Hearing deficiency, resulting in social isolation Prisoners in solitary confinement; refugees; immigrants, all of whom experience solitary isolation Low socioeconomic status Paranoid, Schizoid, or Avoidant Personality Disorder which may be associated with Delusional Disorder

Diagnosis Diagnosis is made on the basis of the systematized and encapsulated delusions, in the absence of other psychotic symptoms that would imply the presence of Schizophrenia, Schizoaffective Disorder, Mania or Depression. General medical conditions, such as thyroid disorders, systemic lupus erythematosus, dementia, etc., should be excluded as the cause of the delusions. In addition, conditions like substance abuse (cocaine, amphetamine, etc.) should also be excluded as the cause of the delusions. Of note is that the patients personality and psychosocial functioning are not significantly affected by the disorder. Based on the DSM-IV, the symptoms should be present for at least a month, whilst based on the ICD-10, the symptoms should be present for at least 3 months.

Differential Diagnosis (a) Physical/General Medical Conditions

Persecutory delusions may occur in physical conditions such as substance abuse (e.g. cocaine) and general medical conditions like thyroid disorders. Thorough medical history, physical examination, and laboratory investigations should be done to exclude these conditions. (b) Paranoid Schizophrenia

In Paranoid Schizophrenia, the delusions tend to be bizarre or absurd, and are accompanied by some of the other features of Schizophrenia, such as prominent auditory hallucinations, thought disorder, passivity influence, and deterioration of psychosocial functioning. (c) Depression

Mood congruent persecutory delusions may occur in Depression, and are usually related to the guilt feelings, in that the individual is convinced that he has done something gravely wrong, for which he is being persecuted. Apart from the persecutory delusions however, a person with Depression would also suffer other accompanying symptoms like anhedonia, anorexia, early morning awakening, diurnal variation of mood, poor concentration, etc. (d) Mania

As in Depression, the persecutory delusions in Mania tend to be mood congruent, and may be secondary to his grandiose delusions of self-importance or wealth; he may be convinced that others want to harm him on account of his status or wealth. However, other features of Mania would also be present, such as restlessness, hyperactivity, expansive or irritable mood, poor concentration, over talkativeness, disinhibited behaviour, etc. (e) Paranoid Personality Disorder

In Paranoid Personality Disorder there is a pattern of pervasive distrust and suspiciousness of others, usually beginning by early adulthood. The affected individual tends to read hidden threatening meanings into innocuous remarks or incidents, or bear

long-standing grudges, and suspect without sufficient evidence that others bear him ill will or harm. Some individuals with Paranoid Personality Disorder may be overly jealous, suspecting that the spouse is carrying on an illicit affair without any concrete justification, while others may be litigious and frequently get embroiled in legal disputes arising from their suspicions of others actions. It is sometimes difficult to differentiate Paranoid Personality Disorder from Delusional Disorder, and, at times, the former may slip into the latter as the affected person is subjected to stress in his middle age or older. Individuals with Paranoid Personality Disorder display their suspiciousness from early adulthood, whilst those with Delusional Disorder develop their symptoms later.

Treatment It is important to decide if the patient requires outpatient or in-patient treatment at the outset. This would be determined by the presence of violence or social difficulties. Involuntary admission may sometimes be necessary to protect the patient or others, especially in pathological jealousy. In treatment the psychiatrist should try to establish rapport and not condemn nor collude with the delusions. Assurance, respect, and psychological support would help in gaining the patients confidence in the therapeutic relationship. Group therapy and interpretative therapy are unsuitable as the patient tends to be suspicious and hypersensitive, and would misinterpret the process. Treatment with neuroleptic medication is indicated. Classical neuroleptics like Haloperidol, Chlorpromazine, or Trifluoperazine may be used. If side-effects are a problem, the newer (and expensive) atypical neuroleptics like Risperidone or Olanzapine may be considered. The chief problem is that the majority of persons with Delusional Disorder have no insight into their problems and almost certainly would reject medications. Attempts should be made to persuade the patient to accept depot injections such as Flupenthixol Decanoate if compliance with oral medications is in doubt. Special mention should be made of the management of pathological jealousy. When the individual resorts to physical violence on his partner because of his intense jealousy, the psychiatrist would have to advise the partner to seriously consider separation, to prevent homicide.

Prognosis The course and prognosis of delusional disorders are variable. Some run a chronic course as the delusions are firmly held and treatment is often rejected. Others may remit completely within a few months, while yet others may remit and relapse over the years. Notwithstanding the refusal of medication, a satisfactory outcome may be temporarily achieved if the psychiatrist is able to dissuade the patient from acting on his abnormal beliefs. This was demonstrated in the case of Ah Seng, who was persuaded to believe that he had done enough to warn the people about the government.

References 1. 2. Howard H Goldman. Review of General Psychiatry. 4th ed. 1995. Pg 239-242. Prentice-Hall International Inc. M Gelder, D Gath, R Mayou and P Cowen. Oxford Textbook of Psychiatry. 3rd ed. 1996. Pg 294-307. Oxford University Press.